Varicella Zoster Virus Meningoencephalitis: A Case Report and Literature Review

1UT Southwestern, Dallas, TX

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 413

Case Presentation:

A 23‐year‐old man with untreated acquired immune deficiency syndrome (AIDS) presented with headache and new‐onset generalized seizure. He had recently been hospitalized at a local community hospital for confusion and behavior changes where he was thought to have viral meningitis. Shortly after discharge from that facility, he had a generalized tonic‐clonic seizure and presented as ill‐appearing and cachectic. His mental status was normal, with no meningeal signs and no focal deficits. There were no current or recent rashes, and the remainder of his exam was unremarkable. CD4 count was 15 cells/ μL. Cerebrospinal fluid contained 19 nucleated cells with lymphocyte predominance and 52 red blood cells; protein was 145 mg/dL, and glucose was 49 mg/dL. Herpes simplex virus (HSV) DNA polymerase chain reaction (PCR) of the cerebrospinal fluid was negative, as were studies for cytomegalovirus, Epstein–Barr virus, and JC virus. Antibodies to Toxoplasma gondii and endemic fungi were negative as well. Magnetic resonance imaging showed a nonspecific focus of fluid‐attenuated inversion recovery signal in the left posterior frontal cortex. With the diagnosis still unclear, the patient was empirically started on therapy for suspected mycobacterial disease and antiepileptics. After 5 days in the hospital, varicella zoster virus (VZV) PCR returned positive, and the patient was started on intravenous ganciclovir to treat the VZV encephalitis and concurrent cytomegalovirus retinitis that was discovered during the same stay. He symptomatically improved and was discharged home after 12 days of treatment.

Discussion:

VZV encephalitis is a rare condition in immune‐deficient individuals, documented in 0.1 %–4% of AIDS patients presenting with neurological disease and is associated with high mortality. Clinical recognition of the disease is difficult, as only 30% of patients present with skin lesions. It is thought that VZV is spread to the central nervous system by hematogenous or neuronal pathways, causing demyelination and vasculopathy. Common neurological findings include headache, seizure, mental status changes, and focal deficits. Use of DNA PCR assists in early diagnosis. Brain imaging has been variable in VZV encephalitis; however, it may reveal spherical white matter lesions lacking surrounding edema. Intravenous acyclovir is used for immunocompromised patients or patients with severe disease.

Conclusions:

HSV is often the primary focus of evaluation and testing for suspected viral menin‐goencephalitis because of its high mortality. This case illustrates that because VZV is a rare cause of encephalitis, it can be overlooked. Hospitalists need to consider the diagnosis of VZV encephalitis in the appropriate setting because it too is associated with high mortality, but with a high index of suspicion it can be readily diagnosed and treated.

Disclosures:

V. Tang ‐ none; M. Burton ‐ none

To cite this abstract:

Tang V, Burton M. Varicella Zoster Virus Meningoencephalitis: A Case Report and Literature Review. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 413. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/varicella-zoster-virus-meningoencephalitis-a-case-report-and-literature-review/. Accessed May 26, 2019.

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